A peer-to-peer review is a phone call between your treating doctor and a doctor who works for your insurance company, where they discuss whether a medical service that was denied or flagged during prior authorization should be approved. It’s one of the most direct ways to challenge an insurance denial, and the success rates are surprisingly high. In radiation oncology, for example, roughly 69% of denials sent to peer-to-peer review were overturned without any change to the treatment plan.
How a Peer-to-Peer Review Works
When your insurance company denies a prior authorization request, or flags it for additional review, your doctor can request a peer-to-peer call. During this conversation, your doctor explains directly to the insurance company’s physician reviewer why the treatment, medication, or procedure is medically necessary for your specific situation. The insurance reviewer then decides whether to approve or uphold the denial.
The call typically lasts 10 to 20 minutes. Your doctor presents your clinical history, explains why alternative treatments aren’t appropriate, and makes the case that the requested service meets the insurer’s coverage criteria. You don’t participate in the call yourself. It happens between the two physicians, though your doctor may ask you for additional details about your symptoms or treatment history beforehand.
These reviews most commonly come up for advanced imaging (like MRIs and CT scans), specialty medications, surgical procedures, and treatments like radiation therapy. Essentially, any service that requires prior authorization can end up in a peer-to-peer review if the initial paperwork doesn’t satisfy the insurer.
Why Denials Get Overturned So Often
The numbers tell a compelling story. In a study of one large radiation oncology department, 123 treatment courses were denied and sent to peer-to-peer review over a seven-month period. Of those, 85 (69.1%) had the denial overturned without any change to the original treatment plan. The Kaiser Family Foundation found an even higher rate across all medical services: an 82% denial overturn rate when appeals were submitted after prior authorization denials in Medicare Advantage plans.
The reason so many denials get reversed is straightforward. Initial prior authorization decisions are often made based on paperwork alone, sometimes by non-physician staff applying standardized checklists. A peer-to-peer call lets your doctor explain the nuances that don’t fit neatly into a form: why your case is different from the typical patient, why the first-line treatment failed, or why delaying care would cause harm. Context matters, and a conversation conveys it far better than a stack of documents.
Who Reviews Your Case
The word “peer” implies the insurance reviewer should be a true clinical peer of your treating doctor, but that’s not always the case. Some states have addressed this directly. Illinois, for instance, requires that clinical reviewers be experts in the patient’s specific medical condition, hold an unrestricted medical license, and carry current board certification in the relevant specialty area. They must also have recent or current experience treating patients with the same or similar conditions.
Not every state has rules this specific, though. The American Medical Association has raised concerns that some insurance companies assign reviewers who practice in a completely different specialty than the treating physician. A general internist reviewing a complex neurosurgical case, for example, may not fully grasp the clinical reasoning behind the request. If your doctor feels the reviewer lacks relevant expertise, that’s worth noting for a potential appeal.
Your Rights During the Process
Federal rules under ERISA (the law governing most employer-sponsored health plans) provide several protections. If your claim is denied based on a medical judgment, the insurer must consult with an appropriate health care professional during the appeal. The insurer must also identify by name the medical experts whose advice influenced the denial. Simply naming the consulting company or listing generic qualifications isn’t enough under federal guidelines.
You have at least 180 days after receiving a denial to file an appeal. If your situation is urgent, you can request an expedited appeal either by phone or in writing. When a plan offers two levels of appeal, each level must involve an independent review. The person reviewing your appeal cannot be the same individual who made the initial denial, nor a subordinate of that person, and they cannot simply defer to the original decision. They must review the full record and make their own independent judgment.
What Happens if the Denial Stands
If the peer-to-peer review doesn’t result in approval, you still have options. Your doctor can submit a formal written appeal with additional clinical documentation. Many states also offer an external review process, where an independent third-party organization evaluates the case. This external reviewer must meet strict qualification standards, including board certification and active clinical experience in the relevant specialty.
The key thing to understand is that a peer-to-peer review is not your last chance. It’s one step in a broader appeals process, and each step involves progressively more independent reviewers. Many patients and doctors give up after an initial denial, which is why the high overturn rates are so striking. The system is designed to be challenged, and the data shows that challenging it works more often than not.
How to Make the Most of It
Even though the call is between your doctor and the insurance reviewer, you can play a role. Make sure your doctor’s office has your complete medical records, including documentation of any treatments you’ve already tried and why they didn’t work. If you’ve seen multiple specialists, ensure those records are consolidated.
Ask your doctor’s office when the peer-to-peer call is scheduled, and follow up afterward to learn the outcome. If the denial is upheld, ask specifically what the reviewer’s rationale was and whether the reviewer was board-certified in the relevant specialty. These details matter if you move forward with a written appeal or external review. Knowing exactly why the insurer said no gives your doctor the best chance of building a stronger case the next time around.